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PREOPERATIVE RADIOTHERAPY OR RADIOCHEMOTHERAPY FOR LOCALLY
ADVANCED RECTAL CANCER PATIENTS: SINGLE CENTRE EXPERIENCE
1
Vassilios , Antoniou
2
George ,
2
Panteleimon ,
Vassiliou
Kountourakis
Efthymiou
4
1,4
2
Petros , Andreopoulos Dimitrios , Papamichael Demetris .
1 Department of Radiation Oncology, Bank of Cyprus Oncology Centre.
2 Department of Medical Oncology, Bank of Cyprus Oncology Centre.
3 Research Department, Bank of Cyprus Oncology Centre.
4 Department of Radiology, Bank of Cyprus Oncology Centre.
3
Maria ,
Polyviou
Introduction
Table 1: Demographic patient characteristics and initial clinical staging
During the last two decades the treatment and overall management of
rectal cancer patients has changed considerably in order to achieve
four main targets: a) reduction of local recurrence rate, b) Increase in
overall survival, c) Maintenance of good sphincter function and d)
quality of life maintenance of patients at high levels.
Total mesorectal excision (TME) is the currently indicated surgical
procedure, achieving a reduction of local recurrence rates from
15-45 % (5 year rates without TME) [1-3], to rates lower than 10%
[4,5]. The high rates of local recurrence in the era prior to TME
called for the need of the administration of pre- or post- radiotherapy
(RT) that may be combined with chemotherapy (CRT).
The studies that established preoperative RT ± Chemotherapy in
Europe are the Swedish [6], Dutch [7,8] and German trials [9]. This
treatment is indicated for locally advanced rectal cancer patients: ≥
T3 and Ν+.
Number (%)
Sex
Tumor location
cTNM staging
Conclusion
Our results are comparable to those reported in large randomised
trials and show that pre-op RT or CRT should be the standard of care
for patients with locally advanced rectal cancer to reduce local
recurrence. However, distant spread continues to be a problem.
Better selection of those at risk, and more effective systemic
therapies are clearly needed.
93 (70.5)
Women
39 (29.5)
Low: up to 5cm
67 (50.8)
Mid (5-10 cm)
53 (40.2)
Upper(10-15cm)
10 (7.6)
ΙΙ
17 (12.9)
ΙΙΙ
81 (61.4)
Positive CRM margin
25 (18.9)
EMVI
Surgical procedure type
Goals and methods
Our goal was to evaluate the therapeutic outcome of patients referred
to our centre with locally advanced rectal adenocarcinoma managed
with preoperative RT or CRT. Patient demographic characteristics
and initial clinical staging are presented in table 1.
Overall, 132 consecutive eligible patients were included in the study.
Either oral capecitabine (825mg/m2 BD) or intravenous 5FU (Mayo
clinic: DeGramont protocol) were administered concurrently with
radiotherapy. Local staging for rectal cancer was carried out by using
MRI whereas possible distant disease was evaluated with CT of chest
and abdomen.
Results
Patients had a median age of 64 years (36-86), and a median follow
up of 36 months. Forty-eight % of patients had a low rectal tumor
(0-5 cm from anal verge). Short course radiotherapy (25Gy in 5
fractions) was administered to16 patients, with the rest receiving
long course CRT (overall dose 50.4 Gy in 28 fractions including a
boost of 5.4 Gy in 3 fractions). Forty-five % of patients received
adjuvant chemotherapy, based on the initial clinical staging.
A complete histopathological response (ypCR) was noted in 12.5%
and 18.1% of stage ΙΙ and ΙΙΙ patients respectively. Local recurrence
was diagnosed in 5 out of 132 patients (3.8%), all with an
incomplete surgical excision (R+). Out of the 5 patients that recurred
locally 4 had a low rectal cancer. At 2 and 5 years, disease free
survival was 79% and 68% respectively, with the corresponding
values for overall survival being 88% and 81%. Figures 1 and 2
present overall survival and disease free survival.
Men
7 (5.3)
Low anterior resection
67 (50.8)
Abdominoperineal resection
35 (26.5)
Hartman
1 (0.8)
Other
10 (7.6)
Figure1: Overall Survival
Figure 2: Disease Free Survival
References
1) Jemal A Murray T, Ward E et al. Cancer statistics, 2005. CA Cancer J Clin 2005 ;55 :10-30.
2) Harnsburger JR, Vernava VM III, Longo WE. Radical abdominoperitoneal lymphadenectomy: historic perspective and current role in the surgical management or rectal cancer. Dis Colon
Rectum 1994;37:73-87.
3) Kapiteijn E, Marijnen C, Colenbander AC et al. Local recurrence in patients with rectal cancer, diagnosed between 1988 and 1992: a population-based study in the west Netherlands. Eur J Surg
Oncol 1998:528-535.
4) Macfarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;341:457-460.
5) Aitken RJ. Mesorectal excision for rectal cancer. Br J Surg 1996;83:214-216.
6) Sweedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in respectable rectal cancer. N Engl J Med;336:980-987.
7) Kapiteijn E, Marijnen CAM, Nagtegaal ID et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638-646.
8) Peeters KCMJ, Marijnen CAM, Nagtegaal ID et al. The TME trial after a median follow up of 6 years. Increase local control but no survival benefit in irradiated patients with respectable rectal
carcinoma. Annals of Surgery 2007;246:693-701.
9) Sauer R, Becker H, Hohenberger W et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-1740.